approach to translating evidence to care for cancer survivors · the survivorship care roundtable:...
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Integrating Agendas: A “Team Sports” Approach to Translating Evidence to Care for
Cancer Survivors
Catherine M. Alfano, PhDVice President, Survivorship
SBM Master Lecture April 2, 2016
Estimated and projected number of cancer survivors in the United
States from 1977-2022 by years since diagnosis
0
2
4
6
8
10
12
14
16
18
20
1977 1982 1987 1992 1997 2002 2007 2012 2017 2022
Nu
mb
er i
n M
illi
on
s
Year
15+ years
10-<15 years
5-<10 years
1-<5 years
<1
de Moor et al, CEBP, 2013;22(4):561-70
Cancer Survivorship Research &
Reports
Cancer Survivors are at risk:
Chronic & Late Effects of Cancer
FatiguePain
LymphedemaSexual
Impairment
Incontinence
Depression, Anxiety
Uncertainty
Poor body image
Relationship changes
Job & Insurance problems
Financial burden
CVD
Recurrence/new cancers
Endocrine dysregulation
Obesity
Diabetes
Osteoporosis
Functional limitations
Disability
Poor Quality of Life
Neuropathy
+ Changes: purpose, priorities
Oeffinger et al, N Engl J Med, 2006
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0 5 10 15 20 25 30
Yrs. From Original Cancer Diagnosis
Cu
mu
lative
In
cid
en
ce Grade 1-5
Grade 3-5
Incidence of Chronic Health Conditions in 10,397
Adult Survivors of Childhood Cancer
Mean age of 26.6 years (18-48 years)
By 30 years post cancer:
• 73% survivors with at least one
chronic health condition
• 42% with a Grade 3-5 (severe,
life-threatening, death)
• 39% had >2 chronic health
conditions
Survivors – 8.2 times more likely to
have a severe or life threatening
condition compared to siblings
Childhood Cancer Survivor Study
% with Limitations:
Survivors vs. General Population
Hewitt, Rowland, Yancik. J Gerontol. 58:82, 2003
Psych
Problems
1+
ADL/IADL
1+
Functional
Work
Group Statistics Mask Individual
Differences
Vs…
Projected Increase in US Cancer
Survivors by 2020
Parry et al, CEBP; 20(10) October 2011
0
2,000,000
4,000,000
6,000,000
8,000,000
10,000,000
12,000,000
14,000,000
16,000,000
18,000,000
20,000,000
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Nu
mb
er
of
ca
se
s
Year
65+
<65
42% ↑
Baby Boomers & Expectations:
What a Difference a Generation Makes
THEN COMING SOON…
Old vs. New Definitions ofQuality of Life
Delivering Survivorship Care
• Who should be responsible for survivorship
care?
Oeffinger & McCabe, JCO 2006
Delivering Survivorship Care –Patient
Preferences
Hudson et al, Ann Fam Med 2012
• 52% survivors want follow-up care from cancer specialist
• Survivor concerns about PCPs:
• Lack of cancer expertise• Lack of involvement w
original cancer care• Lack of care continuity
Delivering Survivorship Care
• Who should be
responsible for
survivorship care?
• Divergent perceptions
about who should
provide care for
survivors
Erikson et al., 2007, JOP
Potosky et al, JGIM 2011
Projected Shortage of Oncologists
Delivering Survivorship Care
• Knowledge gaps among PCPs (& oncologists)
Potosky et al, JGIM 2011
Costs of Cancer Care (US)
• $157.77 billion by 2020
• Survivorship excess medical costs: $25-48
billion
• Lost productivity among survivors: $8-16
billion
Costs of Cancer Care (Survivors)
Survivors 2.65 X more likely to file bankruptcyRamsey, Medical Affairs, 2013
Bankruptcy among survivors: 1.79 X higher risk of mortalityRamsey, JCO, 2016
Yabroff, JCO, 2016
Effective, Efficient Care
Doing the right things
Doing the right things right
Doing things
Doing things right
High EfficiencyLow Efficiency
Low Effectiveness
High EffectivenessEfficiency: Doing things rightEffectiveness: Doing the right things
What Does “Doing the Right Things
Right” Look Like for Survivors?
• “Whole person” survivorship care focused on
creating healthy survivors
• Goal: Develop efficient pathways of care
– Keep people OUT of the healthcare system as much
as possible
– Intensity of care varies with need
– Prevent long-term problems to lighten load in primary
care
– Engage patients; Leverage technology
• Coordinate care
• Increase the VALUE of care (outcomes vs. cost)
IOM 4 Pillars of Survivorship Care
• Surveillance
– Recurrence, 2nd cancers, late effects
• Intervention for treatment consequences
– Medical/psychosocial/economic
• Prevention of recurrence/new CAs, late
effects, new comorbidities, disability
• Coordination between PCP, ONC, and
specialists to ensure all needs are met
• For comprehensive, patient-centered care
Screening, surveillance for new/recurrent cancers
Management of late/ long-term effects
Psychosocial, Rehabilitation, & Palliative Care
Specialist care (Cardiac, Endo, Ortho)
Prevention, lifestyle recommendations
Coordination of carePatient
&Family
Hematologist/Oncologist
ONC Nurse
Cancer Rehabilitation Team
Palliative Care Team
Psychologist/Psychiatrist
Social Worker
Pharmacist
Primary Care MD, PA, APRN
Dentist
Specialty providers (CV, Endo, Ortho)
Clinical Care Follow-up Guidelines
• Prostate Cancer – Published online in CA Cancer J Clin on June 10, 2014.(www.bit.ly/ACSPrCa)
• Colorectal Cancer – Published online in CA Cancer J Clin on September 8, 2015. (bit.ly/acscolorc)
• Breast Cancer – Collaboratively developed and released with ASCO. Published online in CA Cancer J Clin and JCO on December 7, 2015. (bit.ly/BrCaCare)
• Head and Neck Cancer – Published online in CA Cancer J Clin March 22, 2016. (bit.ly/acsheadneck)
• Insufficient data to develop guidelines for other cancer sites at this time
Clinical Care Follow-up Guidelines
Guidelines are Useless if We Cannot
Deliver Guideline-Consistent Care
Next Step:
How Do We DELIVER High-Quality
Survivorship Care?
How Do We Get to the Future?
Need Multi-modal, “Team Sport” Partnership Approach
Policy Makers
Clinical Educators
Healthcare Payers
Clinicians
Survivors & Families
Public Health, Community partners
Healthcare Administrators
Industry
ResearchersAdvocacy
Health IT, EHR vendors
Employers
“Team Sport” Strategies to Improve Survivorship Care
Individualized Care Pathways
Legislative/Regulatory/Policy
Technology, Digital health, EHR innovation
Assessment, triage, & surveillance
Healthcare Delivery Innovation
Patient activation/empowerment
Provider Training
1. Assessment, triage, and surveillance• “Precision medicine” Comprehensive Assessment of
Needs & Resources: Integrate molecular, genomic, cellular, physiological, clinical (w PROs), behavioral, and environmental data
• Risk-stratify into care pathways
•Modeling: supercomputer, systems science
• Repeat Assessments: Ongoing surveillance for survivors’ needs
WHO?
2. Create individualized care pathways:
• Targeted: Identify what works for whom? Type & Dose? Especially older adults
• Feasible interventions (survivors & system)
• Assess outcomes: morbidity, referrals, costs, mortality; outcomes that matter to survivors
• Change the process of conducting research—improving communication, collaboration, evaluation, and feedback through partnerships w ALL stakeholders
WHO?: All
Creating Better Research through Partnerships
T3
T1
T2
T4
T0Technology
Multi-level
Analysis
Collaboration (Researchers,
Survivors, Clinicians,
Stakeholders)
The Translational Science Process for Survivorship
Modified from Lam et al; CEBP 2013; (22); 181-8
Survivor Population Health &
Disease Burden
Scientific Discovery
Promising Applications &Interventions
Evidence BasedRecommendations ,
Guidelinesor Policies
Programs in Practice,Organization, &
Community Settings
Describe
health outcomes& determinants
Mechanisms; Preclinical Studies;
Phase I & II trials
Evaluation of Interventions
(Phase III Trials)
Implementation &
Dissemination in real-world settings
Evaluating outcomes inreal-world settings
Knowledge
Integration
Change our Thinking about “Outcomes” to Translate Science into Care• Differ with intended audience
• Providers: morbidity, mortality, referrals, clinic flow
• Survivors: morbidity, mortality, feasibility, out of pocket costs
• Payers: outcomes, costs, ROI
• Legislators & Regulators: new care model value & off-sets
Collect Data to inform USPSTF*:• Intervention effects by symptoms, comorbidities
• Feasibility of referral from primary care
• Dose response for different outcomes
• Independent contribution of intervention components
• Adverse events/potential harms
• Use standardized measures to facilitate pooling
• Intervention effects on health outcomes, prognosis, intermediate markers
*Murray DM, Kaplan RM, Ngo-Metzger Q, et al. Enhancing Coordination Among the USPSTF, the AHRQ, and the NIH. American Journal of Preventive Medicine, 2015, Sept; 49 (3 Suppl 2), S166-73
*These same data will help make the case to other funders as well
3. Patient Activation & Empowerment
• Help survivors self-manage health, become active participants in care = ↑ care efficiency, ↑ adherence, better outcomes
• mHEALTH tools, education, communication & decision making aids
• Workplace solutions
WHO?
4. Provider Training
• Medical school education in survivorship (oncology, primary care, nursing, pharmacy)
• Hybrid practitioners (cardioncology, cancer rehabilitation, palliative care)
• Continuing education for existing workforce
WHO?
E-Learning Series for Primary Care Providers
www.cancersurvivorshipcentereducation.org
ASCO/Primary Care Training
5. Healthcare Delivery Innovation
• Interventions: meet the IHI triple aim
• Improve referral, care coordination, & communication
• Develop tech, mHEALTH, EHR tools to facilitate guideline-consistent care delivery
WHO?
6. Legislative, Regulatory, Policy Reform
• Legislative: Reform insurance coverage:
• Care coordination
• Care planning
• Survivorship care interventions
• Regulatory: Reform carrots & sticks
• CoC, ASCO QOPI
• Revise CMS Oncology Care Model (bundle) to optimize survivorship
WHO?
6. Legislative, Regulatory, Policy Reform
WHO?
Policy
Need Multi-modal, “Team Sport” Partnership Approach
How do we get everyone together?
Policy Makers
Clinical Educators
Healthcare Payers
Clinicians
Survivors & Families
Public Health, Community partners
Healthcare Administrators
Industry
ResearchersAdvocacy
Health IT, EHR vendors
Employers
New National Initiative to Serve as “Coach”:
ACS & ASCO are founding:
The Survivorship Care Roundtable: •Bring together organizations with a stake in the care of cancer survivors
• Clinical groups, advocacy, industry, lifestyle change, payers, regulators, policy makers
•Overarching goal: enhancing delivery of survivorship care to meet survivors’ needs and keep them active and functional •Tackle agendas that no one organization can do alone
The Survivorship Care Roundtable: Subgroups will tackle each of these collaborative agendas:• Assessment, triage, & surveillance• Individualized Care Pathways• Patient activation and empowerment• Provider training• Healthcare delivery innovation• Legislative, regulatory, policy reform
*All leveraging changing technology
New National Initiative to Serve as “Coach”:
Understand Their Specific Motivators, Realities of their Business Model
• What will they get out of participation?
• ROI?
• Value added?
• Drivers are Different…
Engaging Stakeholders
Stakeholder …is motivated by:• Manuscripts, Grant funding
Tenure & Promotion
• Healing as many patients as possible; Easy clinic flow
• Meeting customer needs to drive market share & revenue
• Making voices count, driving patient-centered care
• Pleasing constituents, getting re-elected
Match the Motivators
Stakeholder …is motivated by:• Manuscripts, Grant funding
Tenure & Promotion
• Healing as many patients as possible; Easy clinic flow
• Meeting customer needs to drive market share & revenue
• Making voices count, driving patient-centered care
• Pleasing constituents, getting re-elected
Match the Motivators
Stakeholder …is motivated by:• Manuscripts, Grant funding
Tenure & Promotion
• Healing as many patients as possible; Easy clinic flow
• Meeting customer needs to drive market share & revenue
• Making voices count, driving patient-centered care
• Pleasing constituents, getting re-elected
Match the Motivators
Stakeholder …is motivated by:• Manuscripts, Grant funding
Tenure & Promotion
• Healing as many patients as possible; Easy clinic flow
• Meeting customer needs to drive market share & revenue
• Making voices count, driving patient-centered care
• Pleasing constituents, getting re-elected
Match the Motivators
Stakeholder …is motivated by:• Manuscripts, Grant funding
Tenure & Promotion
• Healing as many patients as possible; Easy clinic flow
• Meeting customer needs to drive market share & revenue
• Making voices count, driving patient-centered care
• Pleasing constituents, getting re-elected
Match the Motivators
Stakeholder …is motivated by:• Manuscripts, Grant funding
Tenure & Promotion
• Healing as many patients as possible; Easy clinic flow
• Meeting customer needs to drive market share & revenue
• Making voices count, driving patient-centered care
• Pleasing constituents, getting re-elected
Match the Motivators
A Challenge Lies Before Us…
THANK yOU,
DEB BOWEN
!!!!!!!
2016 SBM Distinguished Research Mentor Awardee
54
CATHER INE. ALFANO@CANCER .ORG
THANK YOU !
CANCER.ORG 800-227-2345
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